ERs hiring fewer docs to save money

[alphaholic06]

Another reason to find an exit strategy.

https://www.npr.org/sections/health-shots/2023/02/11/1154962356/ers-hiring-fewer-doctors

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[NYEMMED]

I saw this article today. Glad they can start publishing this and showing the public. Time to throw the CMGs under the bus...

 

[Mount Asclepius]

The inherent value of an EP over a MLP isn’t easily appreciable by the general public as individuals since understanding pathophysiology is hard (poor health literacy for most with wide knowledge gap between lay public and physicians) and the benefits are more systemic requiring comparison between individuals - shorter LOS, decreased use of unnecessary testing, lower costs, and improved care. Not to mention the need by physicians to consciously and ethically ration care that not every individual is going to understand. I.e. you can’t get a nonemergent MRI of you knee for your ligamental damage in the ED at 3 AM, and 90 year old grandmother doesn’t get ECMO on her way out the door of life.

More publicity to the issue is really important. Although I do worry society is going to miss the point and errantly think the solution is to cut compensation to physicians. The corporatization of health care is driving expense. PE and insurance middle men/women taking a cut. Midlevel managers everywhere in the false disguise of quality (You know what’s quality? Doctors who trained for 10,000s of hours). Pharmaceutical profiteering. Companies are doing well. The health of America is not.

 

[Major]

Haha of course the president of the PA organization stands up for CMGs and Private Equity. She knows where her bread is buttered!

Thanks for sharing op

 

[RustedFox]

I've had it with the pretenders at my site.
Every shift, the last one goes home at 10pm and says: "Oh, hey - I have 3 or 4 sign-outs for you" and they're invariably all effed up.

Pretender might as well say something like: "I started to work this up, but I didn't have any real idea what I was working up, and when I saw numbers, I didn't know what they meant... so... Here you go."

At least they're not oppositional-defiant like the ones as my last gig were.

We need to "save money"? Fire the admins. It sounds to me like they've failed.

 

[RustedFox]

The problem is envision/TH/APP. I dunno why any physician would work for them given how much bad press they get. TH has literally been sued for cheating docs out of wages and people continue to work for them... Mind blowing. Envision's dream would be to replace all ER docs with APPs and have them consult CRNAs and surgical APPs for any procedures.

Many of us don't have much choice, amigo.

Never thought I'd say this, but Envision is the least of the evils.

 

[Major]

I’m surprised USACS was not in the article.

 

[calvnandhobbs68]

Haha of course the president of the PA organization stands up for CMGs and Private Equity. She knows where her bread is buttered!

Thanks for sharing op

“Jennifer Orozco, president of the American Academy of Physician Associates”

100% positive Jennifer double checked when they quoted her to make sure they put “physician associates” in the article.

 

[bravotwozero]

Many of us don't have much choice, amigo.

Never thought I'd say this, but Envision is the least of the evils.

Have to agree. At least they're much more willing to dole out bonuses, to fill up shifts. Unlike the scrooges at APP.

 

[EctopicFetus]

Have to agree. At least they're much more willing to dole out bonuses, to fill up shifts. Unlike the scrooges at APP.

Envision is about to get their cash infusion from selling a big chunk of their joint venture with hca to hca. Doubt it will be enough. The nsa is gonna bleed the companies.

For those wondering I have it on good news reporters are crawling into the usacs crevasses to expose them too.

I think it might be right that envision is the least crappy of the cmgs.

 

[alpinism]

Lol Envision is the worst of the worst of CMGs.

May I remind everyone who is primarily responsible for destroying the specialty due to all these new HCA residencies.

They're also notorious for staffing their 50K visit trauma centers with single coverage docs and NP midlevels.

The main difference is Envision pays a better salary for their physician puppets.

 

[bravotwozero]

Lol Envision is the worst of the worst of CMGs.

May I remind everyone who is primarily responsible for destroying the specialty due to all these new HCA residencies.

They're also notorious for staffing their 50K visit trauma centers with single coverage docs and NP midlevels.

The main difference is Envision pays a better salary for their physician puppets.

Envision isn’t funding those residencies, HCA is. Envision doesn’t have the money for that anyway, it’s HCA with a $300 billion market cap, while envision is insolvent. Envision has no control over that process.

 

[Old_Mil]

They're also notorious for staffing their 50K visit trauma centers with single coverage docs and NP midlevels.

Seriously? That's far worse than I could have possibly imagined it to have gotten.

 

[EctopicFetus]

Envision isn’t funding those residencies, HCA is. Envision doesn’t have the money for that anyway, it’s HCA with a $300 billion market cap, while envision is insolvent. Envision has no control over that process.

It’s an HCA thing for sure but envision could tell them it’s a bad idea. Of course they won’t since who doesn’t want cheap labor. If you think MLPs are ok residents who are bottom of the barrel are still better.

 

[AlmostAnMD]

Seriously? That's far worse than I could have possibly imagined it to have gotten.

lol

not paying a lot of attention

It's a model for the future. Even major centers will one day have just a single doc supervising 4-5 midlevels that really run the place

AAEM is betting the public will care about better quality

but gov't is doing most of the funding, and a 5-10% miss rate for a >50% decrease in costs speaks louder than quality care

the futureeeeeeeeeeeeeee

 

[CoolDoc1729]

Seriously? That's far worse than I could have possibly imagined it to have gotten.

My place is ~40k with 35% admission rate … about 6 months ago a bunch of midlevels quit .. they did not offer the shifts to the docs or adjust the schedule at all, I was just alone from 11p-6a seeing 30+ every shift. I don’t foresee the insurance companies or hospitals having any incentive to reel in this behavior, obviously the CMGs want to $pend le$$, so I really think they will push the limits until even the 65k type sites are single physician coverage.

 

[EctopicFetus]

lol

not paying a lot of attention

It's a model for the future. Even major centers will one day have just a single doc supervising 4-5 midlevels that really run the place

AAEM is betting the public will care about better quality

but gov't is doing most of the funding, and a 5-10% miss rate for a >50% decrease in costs speaks louder than quality care

the futureeeeeeeeeeeeeee

It’s an interesting perspective. I personally think (and hope) you have it wrong. Keep in mind what they pay us is minuscule as compared to the cost of the care we provide. Hospitals don’t care. Insurers and therefore Medicare do care.

Then Noctor doesn’t know something and admits a patient unnecessarily from the Ed. That’s a major cost. Order a ct that’s not needed. Big money.

What we are paid is tiny as compared to the amount of other peoples money we spend on shift. Noctors spend a lot more for the same patient than we do. Discharge someone and they have a bad outcome. That’s a huge cost difference. It sounds simple to the public but being right makes a difference. Being nice feels better to the public. Getting your z pak and steroid and an unnecessary ct makes the patient feel heard but that just tacked on $1000 in wasted cost.

 

[EctopicFetus]

My place is ~40k with 35% admission rate … about 6 months ago a bunch of midlevels quit .. they did not offer the shifts to the docs or adjust the schedule at all, I was just alone from 11p-6a seeing 30+ every shift. I don’t foresee the insurance companies or hospitals having any incentive to reel in this behavior, obviously the CMGs want to $pend le$$, so I really think they will push the limits until even the 65k type sites are single physician coverage.

God bless you. Real question. Why would you see more than 2.0-2.2 pph? I wouldn’t kill my self or take the med mal risk pushing like you did.

 

[emergentmd]

I was just alone from 11p-6a seeing 30+ every shift.

You are much tougher than I am b/c you must be staying 2+ hrs back to clean up/finish charting for free. I am super efficient but 4+/hr on an overnight shift where a bad night prob is 40+ pts is a recipe for some bad outcomes.

 

[CoolDoc1729]

God bless you. Real question. Why would you see more than 2.0-2.2 pph? I wouldn’t kill my self or take the med mal risk pushing like you did.

On a systems level I know it is feeding the beast, but I care about the staff and the patients and on a micro level I’d rather do my best to get all the non sick home and all the actually sick out of the wr. I generally leave on time with all charts done. Obviously if anyone is actually sick or time consuming lac etc then I can’t get to 30. I work hard and am fairly efficient but I don’t kill myself.
Re: the medmal risk: unfortunately I think if someone sits in the waiting room unseen I am still exposed to liability if I am the “provider” on duty, no?

 

[emergentmd]

On a systems level I know it is feeding the beast, but I care about the staff and the patients and on a micro level I’d rather do my best to get all the non sick home and all the actually sick out of the wr. I generally leave on time with all charts done. Obviously if anyone is actually sick or time consuming lac etc then I can’t get to 30. I work hard and am fairly efficient but I don’t kill myself.
Re: the medmal risk: unfortunately I think if someone sits in the waiting room unseen I am still exposed to liability if I am the “provider” on duty, no?

If you are seeing 4pph, unless they are all cough/cold, how in the work are you leaving on time. I was probably the fastest doc in our group and once I hit 3pph, It became hard to finish on time. No way I am dong a pt every 15 min unless its all cough/cold. If you did, more power to you but I bet not many docs could see 4pph in an overnight shift so you are killing yourself for very little gain.

 

[xaelia]

On a systems level I know it is feeding the beast, but I care about the staff and the patients and on a micro level I’d rather do my best to get all the non sick home and all the actually sick out of the wr.

This sort of individual heroism is music to shareholders' ears.

 

[Arcan57]

If you are seeing 4pph, unless they are all cough/cold, how in the work are you leaving on time. I was probably the fastest doc in our group and once I hit 3pph, It became hard to finish on time. No way I am dong a pt every 15 min unless its all cough/cold. If you did, more power to you but I bet not many docs could see 4pph in an overnight shift so you are killing yourself for very little gain.

If you have a proactive relationship with your nocturnist hospitalist you can push into the upper 3s and still finish on time. Basically it compresses things where obvious admits and obvious discharges both take about the same amount of time, the only people that slow you down are surgical patients and the truly fence sitting home vs. obs patients. Downside is that you never have time to talk to any of your patients post disposition decision and you're prone to miss things on the admitted patients so it's reliant on your hospitalist's willingess to handle consults based on unexpected CT results/etc.

 

[Brigade4Radiant]

Even though we show a clear benefit for the patients it doesn’t matter people rarely look at savings with time. They look at the right now cost.

 

[wholeheartedly]

Even though we show a clear benefit for the patients it doesn’t matter people rarely look at savings with time. They look at the right now cost.

Hospital admins are notoriously penny wise pound foolish.

 

[NYEMMED]

Lol Envision is the worst of the worst of CMGs.

May I remind everyone who is primarily responsible for destroying the specialty due to all these new HCA residencies.

They're also notorious for staffing their 50K visit trauma centers with single coverage docs and NP midlevels.

The main difference is Envision pays a better salary for their physician puppets.

Seriously? That's far worse than I could have possibly imagined it to have gotten.

I was at a Teamhealth site. It was a high volume, high acuity, Trauma/Stroke/STEMI center

We had 2 physicians and 2 midlevels around the clock and they changed it to 1 physician and 1 midlevel overnight.
They didn’t seem to understand that having 2 level 1 traumas at the same time was impossible by yourself with a midlevel while having to see 30+ patients and sign outs…

I left that job pronto…

 

[CoolDoc1729]

If you are seeing 4pph, unless they are all cough/cold, how in the work are you leaving on time. I was probably the fastest doc in our group and once I hit 3pph, It became hard to finish on time. No way I am dong a pt every 15 min unless its all cough/cold. If you did, more power to you but I bet not many docs could see 4pph in an overnight shift so you are killing yourself for very little gain.

My shift is 2200-0800, so it’s really 3 pph. But the plan was just for me to be along those 7 hours when the midlevels that were supposed to overlap until 0300 quit. (Many patients are the waiting room leftovers from earlier who I just have to talk to, go over results, dispo, maybe 20% I need to add another round of testing; these I do have to do an actual H&P because the midlevels miss a lot of stuff, but at least I don’t have to chart a full H&P as they do that.. I just have to do mdm because theirs are usually a rambling mess than includes no actual decision making or medicine.)

My point was not what a hero I am (lol) but that even a fairly busy place as mine, the solution to all the midlevels quitting was just to leave the night doc to figure it out even though clearly our volume is too high for this. When I started the hospital ceo had a deal with the SDG that we could not average over 2.2 pph and midlevels could not see esi 1-3. It’s been 10 years and now no one cares. I’m sure in the next decade anywhere under 70k will be single staffed supervising midlevels. I hope the cmgs collapse as I think an employed model is more likely to have safer staffing ratios than the cmgs.

 

[Arcan57]

My shift is 2200-0800, so it’s really 3 pph. But the plan was just for me to be along those 7 hours when the midlevels that were supposed to overlap until 0300 quit. (Many patients are the waiting room leftovers from earlier who I just have to talk to, go over results, dispo, maybe 20% I need to add another round of testing; these I do have to do an actual H&P because the midlevels miss a lot of stuff, but at least I don’t have to chart a full H&P as they do that.. I just have to do mdm because theirs are usually a rambling mess than includes no actual decision making or medicine.)

My point was not what a hero I am (lol) but that even a fairly busy place as mine, the solution to all the midlevels quitting was just to leave the night doc to figure it out even though clearly our volume is too high for this. When I started the hospital ceo had a deal with the SDG that we could not average over 2.2 pph and midlevels could not see esi 1-3. It’s been 10 years and now no one cares. I’m sure in the next decade anywhere under 70k will be single staffed supervising midlevels. I hope the cmgs collapse as I think an employed model is more likely to have safer staffing ratios than the cmgs.

It's hard to fathom how the simple dream of making money from the emergency department without having to work in the emergency department got so perverted.

 

[WorkNoteEmergency]

Good article, thanks for posting.

Like a lot of these articles, this one chooses a patient example that seems to comment on a different problem in the system. Lady having a presumably early pregnancy miscarriage visits the ER 3 straight days until she completes it. There may likely have been a problem on visit #1 where no one told her “you’re having a miscarriage and here’s what’s going to happen”, but the more obvious problem to me is there wasn’t an OB office that was available or willing to evaluate her within 24 hrs for follow up. Most everyone, except for most of us, view the ER as a place to go to see a doctor (or “provider” now I guess) rather than a clinic to identify and treat emergency conditions.

A lot of administrators don’t get that a high functioning and efficient ED will likely be a sunk cost but it benefits the entire system by allowing inefficiencies elsewhere, like staff primary care offices with cheap labor who will refer to ED to see real doctors, keeping consultants happy by not getting middle of night phone calls, and not getting called in for simple things, etc. Of course, even this gets tossed out the door when the ED gets turned into a stand alone profit center for a CMG.

This article should also be paired with examinations of administrative bloat. My hospital employed physicians group, over the years has expanded from a couple of practicing physicians running it with admin staff of 2 or 3 people to currently, COO and CFO (non physicians) , CMO, 2 or 3 other senior executives, all with their own secretaries to send out emails for them. The hospital has parallel management and recently hired a “Chief Value Officer” whose work day, I’m sure, does not include examination of the value he provides to the organization.

When I submitted my resignation letter a few weeks ago I got an email from a secretary “on behalf of” one of the executives asking to meet with a third person (maybe a contractor) to get my reasons for leaving. I politely declined but offered to submit a written list of reasons if desired. I mistakenly replied to the executive instead of the secretary, got no response, until a couple of days ago when the secretary sent a follow up email. Meanwhile we get request for Press Ganey surveys to gauge workplace climate all the time when I have seen an exec in the ED maybe twice, three times in the past 2.5 years (Not counting the time CEO came down to peak out the door when somebody threatened to come in and shoot up the ICU when granny died for Covid). I honestly don’t know what those people do all day.

 

[EctopicFetus]

It is correct that admin bloat has gone insane. What is comical and sad to me is that these non revenue generators suck up the time of those who provide patient care and therefore generate income.

I have gotten a handful of completely *****ic emails/ calls from these people. My solution is to always push back and give them more work to do. I used to do this work myself but realized that they didnt care that I put forth effort into a response. Now I place the burden on them to show me the data/proof. It is an amazing tactic as it makes them feel you are engaged and gives them something to do during the bankers hours they work.

 

[Major]

Dr. G hits the nail on the head again. I thought this video relevant

 

[Lexdiamondz]

My place is ~40k with 35% admission rate … about 6 months ago a bunch of midlevels quit .. they did not offer the shifts to the docs or adjust the schedule at all, I was just alone from 11p-6a seeing 30+ every shift. I don’t foresee the insurance companies or hospitals having any incentive to reel in this behavior, obviously the CMGs want to $pend le$$, so I really think they will push the limits until even the 65k type sites are single physician coverage.

Tell that to the med students who "can't see themselves doing anything else"

Had an MS3 yesterday tell me that I lacked perspective for saying that the quality of jobs in EM has decreased in recent years...audibly laughed in his face at that one.

 

[RustedFox]

Tell that to the med students who "can't see themselves doing anything else"

Had an MS3 yesterday tell me that I lacked perspective for saying that the quality of jobs in EM has decreased in recent years...audibly laughed in his face at that one.

Wow.
What an ostrich.

 

[GonnaBeADoc2222]

He's probably also obsessed with matching a "powerhouse residency." So naive.

He will go to Denver EM, then take a job w USACS for 120/hr, and drive 2.5 hrs to Breck on a Saturday to wait 5 hours on a lift line.

 

[EctopicFetus]

He will go to Denver EM, then take a job w USACS for 120/hr, and drive 2.5 hrs to Breck on a Saturday to wait 5 hours on a lift line.

An idiot is born every second. its a sad state of affairs for many of these people.

 

[CoolDoc1729]

An idiot is born every second. its a sad state of affairs for many of these people.

And the thing is, I like the actual work, it’s just becoming harder to do it and for less money and this will continue to be the case … it’s surely not a “lifestyle specialty” good for family life or for longevity nor the most lucrative specialty. The med students get such a skewed viewpoint and they should be grateful if someone is honest with them. I had a FP resident rotating and she’s planning to do the EM fellowship, I’m literally like wow that would not be smart and explained why .. she has no clue .. blithely ignorant .. at least she will have FP to fall back on and just wasting a year of attending life 🤷🏻‍♀️

 

[EctopicFetus]

And the thing is, I like the actual work, it’s just becoming harder to do it and for less money and this will continue to be the case … it’s surely not a “lifestyle specialty” good for family life or for longevity nor the most lucrative specialty. The med students get such a skewed viewpoint and they should be grateful if someone is honest with them. I had a FP resident rotating and she’s planning to do the EM fellowship, I’m literally like wow that would not be smart and explained why .. she has no clue .. blithely ignorant .. at least she will have FP to fall back on and just wasting a year of attending life 🤷🏻‍♀️

Spoke to a friend of mine who works at a place where they do these fellowships. He says all their docs are being pushed rural and having a hard time finding a job. As there is a glut of em docs we will be pushed more and more rural. It is already happening in many southern cities and these now rural em docs are just waiting for the city jobs to open. The path forward will be a difficult one for the fellowship trained fps as the EM trained docs will hold onto these rural sites. If you are in a growing city with more hospitals opening there is some hope but there is no simple solution to the corporatization of medicine especially EM. MLP creep, falling reimbursements Etc.

 

[mike-sheree]

Another reason to find an exit strategy.

https://www.npr.org/sections/health-shots/2023/02/11/1154962356/ers-hiring-fewer-doctors

Visiting from pathology. Read this today. I have tremendous respect for your specialty. You’ve saved my life. Out of curiosity, just what DO you do if/when the s***hits the fan and there is only one real physician on site. I would be scared to death.

 

[CoolDoc1729]

Visiting from pathology. Read this today. I have tremendous respect for your specialty. You’ve saved my life. Out of curiosity, just what DO you do if/when the s***hits the fan and there is only one real physician on site. I would be scared to death.

It’s not great when there are multiple critical patients simultaneously. If I have a good reason I recruit other services - eg if someone is not fully worked up but I know they will end up in icu I go ahead and call the icu resident. If they have an injury requiring admission I don’t wait for all the other injury diagnoses before I call trauma surgery. Etc. I rarely have more than two critical people at the same time. The company I work for expects us to also see everyone within half an hour of signing in, in the waiting room - I try harder than most but obviously that’s not possible if I have someone critical in the back. Then every month the company sends all of us a spreadsheet and asks how we could have 3% LWBS when we didn’t even see very many patients and we have allllll these hours. The gaslighting is to a bizarre degree. This question could be easily answered if they spent one shift with me. I’m the night weekend person… their data says no one comes in on my shifts .. I always see 25-30 patients though! Thankfully no one says a word to me about metrics though besides the emails sent to everyone (so they clearly know their gaslighting is gaslighting)

 

[emergentmd]

It’s not great when there are multiple critical patients simultaneously. If I have a good reason I recruit other services - eg if someone is not fully worked up but I know they will end up in icu I go ahead and call the icu resident. If they have an injury requiring admission I don’t wait for all the other injury diagnoses before I call trauma surgery. Etc. I rarely have more than two critical people at the same time. The company I work for expects us to also see everyone within half an hour of signing in, in the waiting room - I try harder than most but obviously that’s not possible if I have someone critical in the back. Then every month the company sends all of us a spreadsheet and asks how we could have 3% LWBS when we didn’t even see very many patients and we have allllll these hours. The gaslighting is to a bizarre degree. This question could be easily answered if they spent one shift with me. I’m the night weekend person… their data says no one comes in on my shifts .. I always see 25-30 patients though! Thankfully no one says a word to me about metrics though besides the emails sent to everyone (so they clearly know their gaslighting is gaslighting)

I admire your drive but this is not sustainable for any ER doc.

I did a locums shift in a busy ER dump where doc/nursing staff was like a revolving door. Had a shift with double doc coverage and in 1 hr had 4 critical care pts, intubated 3 and 2 Central line. 4th was a pedi status that I was close to putting down too. The other doc did absolutely nothing b/c he sucked and staff knew he sucked so kept coming to me. Only reason I came back was pay was $500/hr. No way am I doing this on a regular basis like you are doing.

 

[mike-sheree]

I think $500/hr should be y’all’s base.

 

[thegenius]

Visiting from pathology. Read this today. I have tremendous respect for your specialty. You’ve saved my life. Out of curiosity, just what DO you do if/when the s***hits the fan and there is only one real physician on site. I would be scared to death.

There are thankfully only a few things that probably the average ER doc gets scared about. And it's different for each doc. I don't like pediatric airway and codes, thankfully I only see them 1/year.

At the end of the day, we have tools. We tube, we line, we start pressors, we give blood, there are a handful of antidotes we have to know about, and that's about all we can really do. If the patient is gonna live, it will require the specialist to come in or we fly them to a specialist.

Most don't realize that if a patient is going to die in the first 10-20 seconds of plopping their arse on the gurney, chances are they won't live. Despite all the high quality CPR we end up doing.

It's interesting death or just about dead doesn't scare me and I'm sure others.. That's easy to take care of.

 

[thegenius]

I think $500/hr should be y’all’s base.

Done. I'll take it.

 

[VA Hopeful Dr]

Tell that to the med students who "can't see themselves doing anything else"

Had an MS3 yesterday tell me that I lacked perspective for saying that the quality of jobs in EM has decreased in recent years...audibly laughed in his face at that one.

Sounds like somebody is not going to get a great grade on their evaluation...

Sadly, I mean both of you.

 

[CoolDoc1729]

I think $500/hr should be y’all’s base.

It is! Then they give $200/h to the MBAs and $100/h to the midlevels

 

[miacomet]

Agreed, just turned down $325 because too low!

 

[WorkNoteEmergency]

Been spending some time with the good Dr G. Maybe the best summary anywhere if the situation.

 

[TooMuchResearch]

Visiting from pathology. Read this today. I have tremendous respect for your specialty. You’ve saved my life. Out of curiosity, just what DO you do if/when the s***hits the fan and there is only one real physician on site. I would be scared to death.

We do our best

 

[TooMuchResearch]

I think $500/hr should be y’all’s base.

Let the major payors know. Appreciate your support. But insurers are cutting rates and prelim data shows our level 5 coding for our particularly sick medicare population are getting down coded in 2023 even with the PITA new documentation that got added onto our old documentation.

 

[lucid_leprechaun]

Let the major payors know. Appreciate your support. But insurers are cutting rates and prelim data shows our level 5 coding for our particularly sick medicare population are getting down coded in 2023 even with the PITA new documentation that got added onto our old documentation.

Yeah I mean it seems like the typical burden is 3-5pts per hour at my sites with APP patients (I see all of them.) If the average patient reimbursement is 160 dollars/pt 500/hr sounds like a deal.